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Modalities A review of commonly used modalities

Determine patient response

Always monitor the patient’s response to modalities

Interview the patient and obtain verbal and non-verbal responses

Identify complications or secondary effects caused by the modality

Determine both positive and negative outcomes from the modality

Modalities Included

Superficial Thermotherapy

Hot packs

Paraffin bath

LASER

Deep Thermotherapy

Ultrasound (US)

Phonophoresis

Cryotherapy

Cold packs

Ice massage

Electrotherapy

Interferential Current (IFC)

Functional Electrical Stimulation (FES)

TENS

Conventional

Acupuncture-like

Brief intense

Burst mode

Modulation mode

Iontophoresis

Intermittent Mechanical Compression

Mechanical Spinal Traction

Superficial Thermotherapy

Indications

Joint hypomobility, musculoskeletal pain/spasm, preparation for exercise or electrical stimulation, subacute or chronic traumatic and inflammatory conditions

Precautions

Cardiac insufficiency, edema, impaired circulation, impaired thermal regulation, metal implants at treatment site, open wounds

Contraindications

DVT, impaired cognitive function, decreased circulation or sensation, malignant tumors, acute and early subacute traumatic and inflammatory conditions, tendency toward hemorrhage or edema, very young or very old patients

Superficial Thermotherapy: Hot Packs

Hot packs

Packs are placed between towels or covers to protect skin

8 layers of toweling should be used

If heat is transferred too quickly, skin mottling or permanent burn damage may occur

Patient’s skin should be checked periodically during treatment

Treatment time: 20-30 minutes

Superficial Thermotherapy: Paraffin

Paraffin

Therapeutic application of liquid paraffin to a body part for the purpose of heat transmission

Often used for small or irregularly shaped body parts such as the hand or foot

Contraindications: open wounds, recent scars or sutures, skin infections, allergic rash


Superficial Thermotherapy: LASER

Light Amplification by Stimulated Emission of Radiation (LASER)

The frequency of the laser light and the type of tissue determines the depth of light penetration

Low intensity “cold” lasers are utilized in rehabilitation settings and may be biostimulative and facilitate healing

Acute conditions: lower energy density ranges of 0.05 and 1 J/cm2 are recommended

Chronic conditions: higher dosages of up to 40 J/cm2 are recommended

Deep Thermotherapy

Indications

Pain modulation, increase soft tissue extensibility, reduce or eliminate soft tissue inflammation or restriction, accelerate tissue healing

Precautions

Metal implants, osteoporosis, primary repair of tendons or ligaments or scar tissue, open epiphyses and healing fractures, acute inflammation

Contraindications

Impaired circulation or sensation, impaired cognitive function, thrombophlebitis, joint cement, plastic components, vital areas (brain, ear, eye, heart, cervical ganglia, carotid sinuses, reproductive organs, spinal cord, cardiac pacemaker, pregnant uterus), use of radium or radioactive isotopes

Deep Thermotherapy: US

Ultrasound (US)

Select appropriate sound head size with an effective radiating area (ERA) of approximately half the size of the treatment area

Example: 1cm2 = wrist; 5cm2 = shoulder or leg

Select the optimal parameters for either a thermal effect of non-thermal effect

Must use a medium (such as US gel) to treatment area and move the sound head at approximately 4 cm/second

Deep Thermotherapy: US

Thermal effect

Intensity: 0.3-1.5 W/cm2

Frequency:

1 MHz for tissue up to 5 cm deep

3 MHz for tissue 1 to 2 cm deep

Duty cycle: continuous, 100%

Non-thermal effect

Intensity: 0.5-1.0 W/cm2

Frequency:

1 MHz for tissue up to 5 cm deep

3 MHz for tissue 1 to 2 cm deep

Duty cycle: pulsed, 20-50%

Treatment time: 5 to 10 minutes for each treatment area that is twice the ERA of the transducer

Example: an area of 20 cm2 treated with a sound head with an ERA of 10 cm2 should take 5-10 minutes

Phonophoresis

Indications

Pain modulation, decrease inflammation in subacute and chronic musculoskeletal conditions

Precautions and contraindications

See US section

Phonophoresis

Used to drive medication through the skin into the treatment area

Common medications include Hydrocortisone, Dexamethasone, salicylates, Lidocaine, or other ointments

Intensity: 1-3 W/cm2


Cryotherapy

Indications

Pain modulation, reduce or eliminate soft tissue inflammation or edema, reduce muscle spasm or spasticity, acute and chronic traumatic and inflammatory conditions, thermal burns

Precautions

Hypertension, impaired temperature sensation, open wounds, application over a superficial nerve, very old or very young patients

Contraindications

Cold hypersensitivity or intolerance, impaired temperature sensation, cryoglobulinemia, peripheral vascular disease, Raynoud’s disease

Cryotherapy: Cold Packs

Cold packs

Keep the patient warm throughout treatment

Dampen a towel with warm water and place cold pack on towel

Place pack on patient and cover with dry towel to reduce warming


Cryotherapy: Ice Massage

Ice massage

Use an ice cylinder formed by freezing water in a paper cup

Patient will experience cold, burning, aching, and then numbness during treatment

Avoid bony areas and superficial nerves

Treatment time: 5-10 minutes or until analgesia occurs

Electrotherapy

Indications

Pain modulation, muscle spasm or re-education or weakness, impaired range of motion, soft tissue repair or wound healing, edema, spasticity, denervated muscle

Precautions

Areas of impaired sensation, severe edema

Contraindications

Healing fractures, areas of active bleeding, malignancies or phlebitis in the treatment area, superficial metal implants, pharyngeal or laryngeal muscles, demand-type pacemaker, myocardial disease

Electrotherapy: Interferential Current (IFC)

Two sinusoidal waves are crossed to generate an amplitude modulated beat frequency

Used for pain modulation or muscle strengthening

Bipolar (premodulated IFC)

Active and dispersive electrodes used over a small area

Quadripolar (IFC)

Two sets of electrodes placed diagonally to one another over a large area

Electrotherapy: Functional Electrical Stimulation (FES)

Also known as neuromuscular electrical stimulation (NMES)

Used for disuse atrophy, limited ROM, muscle re-education or spasm or spasticity

Also used in combination with or instead of an orthotic device

Alternating current is used to stimulate innervated muscle for general stimulation

Direct current is used for denervated muscle

Electrotherapy: Functional Electrical Stimulation (FES)

Duty cycle

Current on:off time in seconds

Ratio should increased as weakness or atrophy increases

1:1 to 1:2 ratio for minimal or no atrophy

1:3 to 1:4 ratio for moderate atrophy

1:5 to 1:10 ratio for severe atrophy

Electrotherapy: Transcutaneous Electrical Stimulation (TENS)

Provides afferent stimulation for pain modulation

Current

Symmetrical or asymmetrical biphasic (AC)

Monophasic (DC)

Electrode placement

Site of pain, dermatome, trigger point, proximal or distal to the pain site, segmental related myotome


Conventional (high rate) TENS

Indicated for temporary relief of acute or chronic pain

Amplitude: comfortable tingling sensation, paresthesia without muscle activation

Pulse rate: 50-80 pps

Pulse duration: 50-100 µsec

Treatment duration: 20-60 minutes

Pain relief duration: temporary

Acupuncture-like (strong, low-rate) TENS

Indicated for chronic pain

Amplitude: strong, comfortable, rhythmic muscle twitches

Pulse rate: 1-5 pps



Pain relief duration: long lasting, possibly >1 hour


Brief intense TENS

Indicated to provide rapid onset, short-term pain relief during painful procedures

Amplitude: patient tolerance

Pulse rate: 80-150 pps


Treatment duration: 15 minutes

Pain relief duration: temporary (30-60 minutes)


Burst mode TENS

Indicated for stimulation of endogenous opiates, analgesia

Amplitude: comfortable, intermittent paresthesia

Pulse rate: 50-100 pps delivered in bursts of 1-4 pps



Pain relief duration: long lasting (hours)



Modulation mode TENS

Used to prevent neural or perceptual adaptation

Frequencies, pulse widths, intensities can be altered by ten or more percent, one or two times per second

Electrotherapy: Iontophoresis

Continuous direct current is used to drive chemical ions through the skin

Therapeutic ion must be placed under an electrode of similar charge

Cathode (negative pole) used for salicylate, acetate, dexamethasone, iodine

Anode (positive pole) used for hydrocortisone, Lidocaine, magnesium, calcium, lithium, zinc, copper

Contraindications

Impaired skin sensation, allergy or sensitivity to therapeutic agent or direct current, metal in or near treatment site, recent scars, cuts, bruises or broken skin

Electrotherapy: Iontophoresis

Clean and inspect the skin before treatment

Dose: product of time and current intensity

Anode: 1.0 mA/cm2

Cathode: 0.5 mA/cm2

Duration: 10-40 minutes

Intensity: turn up slowly to selected level

Observe treatment area every 3-5 minutes and after treatment


Indications

Chronic edema, postmastectomy lymphedema, stasis ulcer, traumatic edema, venous insufficiency, amputation

Precautions

Uncontrolled hypertension, impaired sensation, malignancy, obstructed lymph or venous return

Contraindications

Acute infection, acute inflammation in treatment area, acute DVT, acute pulmonary edema, arterial insufficiency, cancer, diminished sensation, edema with cardiac or renal impairment, cardiac or renal insufficiency, impaired cognition, infection in treatment area, obstructed lymph channels, very young and frail elderly patients


Assess patient’s blood pressure in order to determine device settings

Elevate the limb

Inflation:deflation ratio is approximately 3:1

Edema reduction at 45-90 seconds:15-30 seconds

4:1 is often used to shape a residual limb

Treatment duration: varies depending on patient tolerance

Lymphedema: 2 hours to two 3 hour sessions

Traumatic edema: 2 hours

Venous ulcers: 2.5 hours 3x/week to 2 hour periods

Residual limb reduction: 1 hour to 3 hour sessions, totaling 4 hours

Mechanical Spinal Traction

Indications

Joint disease or hypomobility, meniscoid blocking muscle spasm, degenerative disc, discogenic pain, herniated nucleus pulposis, nerve root impingement, subacute or chronic joint pain

Precautions

Acute inflammation aggravated by traction, claustrophobia, acute strains or sprains, hiatus hernia, joint instability, osteoporosis, pregnancy, TMD with halter use

Contraindications

Rheumatoid arthritis, impaired cognitive function, spinal tumors, spinal infections, spondylolisthesis, vascular compromise, vertebral artery syndrome, very young or very old patients

References

Cameron MH, Physical Agents in Rehabilitation: From Research to Practice. St. Louis, MO; Elsevier; 2003.

O’Sullivan SB, Siegelman RP, IER’s National Physical Therapy Examination Review & Study Guide. Evanston, IL; International Educational Resources, Ltd.; 2008.

Siegelman R, Bianco T, Dirkes A, Chavez E, IER/TherapyEd Exam Preparation: Physical Therapy Course Manual version 4.0. Evanston, IL; International Educational Reources, Ltd.; 2008.

American Physical Therapy Association. Minimum required skills of physical therapist assistant graduates at entry-level BOD G11-08-09-18. Available at: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/BOD/Education/MinReqSkillsPTAGrad.pdf#search=%22pta%20minimum%20skills%22. Accessed December 20, 2012.

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